Providers

Provider Portal Registration Form

Only one use per office. We suggest a generic login

First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
Phone:
Fax:
Your E-Mail:
Challenge Question: Will be used for Password Changes
Challenge Response: Will be used for Password Changes
User ID: Used to login
Password: Used to login
TIN Number:
Authorized by: Insert First Name, Last Name

As a provider of dental/medical procedures, it is your responsibility to ensure that user passwords are changed in the event of staff turnover in order to protect patient PHI.